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3 months PTA, patient had fever, cough and colds. Consult done at a local health center where she was given amoxicillin for 1 week with noted resolution of symptoms. However, after 1 week, there was recurrence of fever, for which she was given co-amoxyclav. There was note of a palpable abdominal mass at this time.
2 months PTA, (+) recurrence of fever, consult done at local health center, given cotrimoxazole with relief of symptoms. • 1 ½ months PTA, (+) recurrence of fever, given cefuroxime for 2 days. Patient then had abdominal pain, gradual abdominal enlargement,(+) inguinal mass on the right. Consult done at local health center, given cloxacillin with no resolution • 3 days PTA, (+) difficulty of breathing associated with on and off fever -> consult
Review of systems • (+) weight loss • (+) anorexia • (+) easy fatigability • (+) abdominal enlargement • (+) constipation
Physical Exam on Admission • Awake, in cardiorespiratory distress • BP 90/60 HR 152 RR 40 T 38 Wt 10.8 kg • pale conjunctivae, anicteric sclerae, (+)multiple cervical lymphadenopathy • Equal chest expansion, (+) crackles, bilateral, decreased breath sounds, right lower lung field • Globular abdomen, liver edge 10 cm below right costal margin (+) 6x7 mass on L flank, (+) multiple inguinal mass, R • full pulses, (+) edema, (-) cyanosis (-) clubbing
Initial Assessment • Pleural effusion, probably • parapneumonic process • PTB • Malignancy Intraabdominal mass, probably • Wilm’s tumor • Neuroblastoma • GI TIB Rule Out Disseminated TB
First thoracentesis • Thoracentesis revealed an exudative pleural effusion 300 cc • yellow, slightly cloudy, RBC 2700 WBC 987 PMN 1% Ly 99%
Bacterial cultures and AFB smears were negative. Histopathologic findings showed negative for malignant cells. • Antibiotics started were cefuroxime and amikacin.
Post thoracentesis, chest xray showed decreased pleural effusion. CTT insertion was done and removed after 3 days
CT scan showed extensive mediastinal and intraabdominal lymphadenopathy, hepatosplenomegaly and pulmonary nodules.
Patient was referred back on the 19th day of admission. • Awake, in mild respiratory distress, RR 45 HR 120 • Pink conjunctivae, anicteric sclerae, multiple lymphadenopathies • Equal chest expansion, (+) crackles, bilateral, decreased breath sounds, right
Chest xray showed increasing infiltrates with recurrence of pleural effusion, Right
Assessment: Recurrent pleural effusion, right probably nosocomial pneumonia vs lymphoma • Repeat thoracentesis was done aspirating 550 cc of light yellow, purulent fluid
Second thoracentesis • Thoracentesis revealed an exudative pleural effusion • reddish orange, hazy, RBC 12,750, WBC 4,480
Repeat CXR showed decreased pleural effusion, expanded right lung • Antibiotics shifted to Vancomycin and Meropenem • CTT insertion was done on the right • On the 5th day after CTT insertion, patient was referred for difficulty of breathing and was intubated. CXR showed fluid accumulation on the left • CTT insertion was done on the left
Patient was extubated after 10 days. Work up was facilitated for possible immunodeficiency. • 1 week prior to demise, patient again started having episodes of fever, with growth of klebsiella on urine culture • 3 days prior to demise, patient was seen drowsy to irritable • 2 days prior to demise, patient was noted with increasing severity of difficulty of breathing.
CBC showed increased WBC count at 31.11 with neutrophils 77%. • 2 days prior to demise, patient was noted tachypneic at 50s, febrile 39.8. • ABG at 10 lpm showed uncorrected hypoxemia 7.465/42.3/61.4 • Patient was intubated and hooked to MV 100% 8 ccc/kg Peep 5 RR 20
Ciprofloxacin started and Amphotericin B ordered. • Day prior to demise, patient was seen with poor sensorium, harsh breath sounds on all lung fields.
Patient had progressively increasing respiraotry distress • ABG on 100% TV 9.3 cc/kg 20 5 • 7.399/45.7/63.5 100% TV 9.3 cc/kg 20 5 • 7.167/57.2/76.6 100% 11 cc/kg 20 7 • 7.142/62.6/62.1 100% 11 cc/kg 30 7
